Identity Disclosure Donor Consent Agreement


Seattle Sperm Bank

Identity Disclosure Donor Consent Agreement

Donor   

I,   (Donor), seek to participate in the donor program conducted by Seattle Sperm Bank. In the event I am accepted into Seattle Sperm Bank’s donor program, I agree to donate semen specimens for the primary purpose of causing pregnancy consistent with the following terms and conditions.

1. Donor Screening

1.1 I agree to make myself available for any laboratory tests that are required during my participation in the program, prior to my termination from the program, and six months after my last donation.

1.2 I agree to report immediately all changes in my health status to the Seattle Sperm Bank while an active donor, and I agree to update my medical history at intervals specified by the Seattle Sperm Bank. I understand that it is particularly important to immediately report all sexually-transmitted disease infections.

1.3 I agree to report any new information about my medical history or that of my family members, which may not have been known or detected during my initial screening. In addition, I agree to be contacted periodically after my termination from the program for the purpose of providing updated information regarding my health and the health of my family members.

1.4 I understand that the Seattle Sperm Bank will pay all laboratory costs.

1.5 I agree to keep the Seattle Sperm Bank informed of my whereabouts during the six-month period after my last donation so that I may be contacted for a final blood draw.

1.6 I agree to remain in contact with the Seattle Sperm Bank indefinitely after my final blood draw has been performed. During this time, I agree to complete a yearly questionnaire via telephone or email. If I fail to contact the Seattle Sperm Bank for completion of a yearly questionnaire in a timely manner, I authorize the Seattle Sperm Bank to use reasonable methods of locating me which may include, but not be limited to, the use of my social security number, TRW credit information or internet searches.

1.7 I understand that Seattle Sperm Bank may contact me at any point after the completion of my time in the program, to request additional genetic testing

2. Donor Products

2.1 I agree to provide to Seattle Sperm Bank various items that may be used by Seattle Sperm Bank for its business, including but not limited to, photograph(s), donor profile, donor essay and audio interview (“Donor Products”). I grant Seattle Sperm Bank the unrestricted right to use and exploit the Donor Products for all purposes whatsoever, including but not limited to, marketing and solicitation of prospective donors and patients, and publishing, displaying and using the Donor Products on Seattle Sperm Bank’s website, marketing materials, or elsewhere, and any and all other uses. I understand I will not receive any additional compensation from Seattle Sperm Bank for the use and exploitation of these products.

    2.1a I consent for Seattle Sperm Bank to use my Adult photo as a Donor Product described in 2.1
   2.1b I do not consent Seattle Sperm Bank to use my Adult photo as a Donor Product described in 2.1

2.2 I acknowledge and agree that the Donor Products are being specially ordered by Seattle Sperm Bank and shall be deemed to constitute and shall be treated as a “work made for hire” for Seattle Sperm Bank under all relevant copyright laws. If, for any reason, pursuant to any relevant copyright laws, the Donor Products or any of their elements shall not be deemed to be a work made for hire for Seattle Sperm Bank, I grant and agree that this Agreement shall constitute an irrevocable, perpetual assignment to the Seattle Sperm Bank and its successors and assigns of any and all of my right, title and interest in and to the Donor Products under any relevant copyright laws. I waive any so-called “droit moral” rights, “moral rights of authors” and all other similar rights however denominated. I agree, on Seattle Sperm Bank’s request, to execute, acknowledge, deliver and/or record such additional documents as Seattle Sperm Bank may deem necessary to evidence and effectuate Seattle Sperm Bank’s rights hereunder. I also hereby appoint Seattle Sperm Bank, as my attorney-in-fact, to execute, acknowledge, deliver and record in the U.S. Copyright Office or elsewhere any and all such documents that I fail to execute, acknowledge, deliver and/or record. I acknowledge that Seattle Sperm Bank is not obligated to exercise any of the rights granted herein or to make any use of the Donor Products provided by me.

3. Donation of Semen Specimens

3.1 If accepted as a participant in Seattle Sperm Bank’s donor program, I agree to make at least one donation per week, but not more than three per week, unless directed otherwise by the Seattle Sperm Bank.

3.2 I agree to abstain from ejaculation for a minimum of 48 hours prior to all semen donations, and I agree to collect all semen specimens on the Seattle Sperm Bank premises.

3.3 I understand that I will be compensated for each semen specimen that meets minimum standards of quality. I further understand that there are certain circumstances under which I may not be compensated for my semen specimen.

3.4 I understand the Seattle Sperm Bank will invest substantial time and money in testing and screening prior to the commencement of my regular donations. Therefore, I agree to make my best effort to remain in the Seattle Sperm Bank program for a minimum of one year. Thereafter, I will be subject to review and contract renewal on an annual basis. I understand that the Seattle Sperm Bank may terminate my participation in the program at any time.

3.5 I agree to provide advance notice to the Seattle Sperm Bank of any intended leave(s) of absence. In addition, I agree to keep the Seattle Sperm Bank informed of my current whereabouts should I change my address or telephone number. I authorize the Seattle Sperm Bank to use reasonable methods of locating me, which may include, but not be limited to, the use of my social security number, TRW credit information or the internet searches.

4. Use of Donor Sperm

4.1 I understand that my donor sperm may be used by customers of Seattle Sperm Bank for the purpose of causing pregnancies via artificial insemination, in vitro fertilization or other methods of assisted reproductive technology. My donor sperm may be used by married women and/or unmarried women, regardless of sexual orientation. I also understand that embryos created with the use of my sperm may be donated by customers of Seattle Sperm Bank for use by other individuals or couples, or for research purposes, including stem cell research. I understand that once I agree to participate in the donor program and have been accepted into the program, I may not impose restrictions on the manner in which my donor sperm may be used.

4.2 I agree that my identifying information can be released to any child(ren) resulting from the deposit of my sperm. This release may take place when any child(ren) born from the donor sperm reaches the legal age of adulthood and submits a request for this information, and understand that in agreeing to this that there is a possibility of future contact with any child(ren) resulting from the deposit of my sperm. This contact may take place when any child(ren) born from the donor sperm reaches the legal age of adulthood and submit a request for contact with their donor. Donor child(ren) will be required to sign a non-disclosure agreement to not publicly share any of the donor’s identifying/contact information with other offspring, on message boards, social media, etc Donor will be notified of the information request and given 30 days to respond to Seattle Sperm Bank. If the donor does not respond within 30 days, the identifying information will be provided to child(ren). Donor may request an initial anonymous contact facilitated by Seattle Sperm Bank prior to his information being released. Seattle Sperm Bank reserves the right to deny access to the donor’s identifying information if the offspring does not agree to the program guidelines.

4.3 I have no intention or desire to be deemed a legal parent of any resulting child(ren) and to the fullest extent possible, waive any and all claims that I may have to parenthood or any child(ren) that may result from my donation(s). I intend for this waiver to apply regardless of whether my semen specimens are used by a married or unmarried woman and regardless of the state or country in which my semen specimens are used.

4.4 I agree not to attempt to discover the identity of the persons for whom I am donating. I understand the nature of the Seattle Sperm Bank’s business and the Seattle Sperm Bank’s relationship with clients, donors and semen depositors. I understand that the Seattle Sperm Bank has assured clients that information pertaining to their relationship with the Seattle Sperm Bank will be held in strict confidence so as to maintain client anonymity.

4.5 I agree that Seattle Sperm Bank may limit the number of pregnancies resulting from use of my donor sperm according to local laws in each country that donor sperm may be exported to.

5. Records/Information

5.1 I hereby authorize disclosure of my medical history and screening information, including genetic and other medical information, to potential recipients of my donor sperm and their physicians.

5.2 I understand that the records of my donations will be kept for at least ten (10) years after semen release for artificial inseminations not resulting in a live birth and for twenty-five (25) years for inseminations resulting in a live birth.

5.3 In the event that I have participated in or applied to any other sperm donor program, I hereby authorize the exchange of information between the Seattle Sperm Bank, Inc. and said sperm donor program.

5.4 I understand that any use, distribution or public release of Seattle Sperm Bank information known to me, including but not limited to names, addresses, any other identifying information, or the nature of business with the Seattle Sperm Bank, concerning any client, other donor or semen depositor is strictly prohibited. I further understand that the use, distribution or public disclosure of any identifying information concerning clients, other donors or semen depositors would result in serious damage to the client, other donors, semen depositors and or the Seattle Sperm Bank.

6. Withdrawal of Consent

6.1 I understand that I have the right to withdraw my consent to the Seattle Sperm Bank’s donor program up until such time that a specific recipient has begun an assisted reproductive cycle in reliance on the availability of my donor sperm. In the event I wish to withdraw my consent, I understand that I am required to provide written notice of such withdrawal to Seattle Sperm Bank by personal service or registered first class mail, return receipt requested.

7. Miscellaneous

7.1 I have read the terms and conditions of the Donor Program contained herein, and I agree to follow the guidelines stated herein while I am participating in the donor program.

7.2 I understand that if I have questions about the program, I may contact the Director of Donor Programs.

7.3 This consent and agreement shall be binding upon me, my assigns, my heirs, executors and administrators.

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Signed by Seattle Sperm Bank
Signed On: June 5, 2019

Signature Certificate
Document name: Identity Disclosure Donor Consent Agreement
Unique Document ID: a50b35be9654414385a07a670c8ddab1e536a8b6
Timestamp Audit
June 5, 2019 12:38 pm PSTIdentity Disclosure Donor Consent Agreement Uploaded by Seattle Sperm Bank - forms@seattlespermbank.com IP 73.42.152.24
June 5, 2019 12:48 pm PSTAlan Dowden - alan@seattlespermbank.com added by Seattle Sperm Bank - forms@seattlespermbank.com as a CC'd Recipient Ip: 73.42.152.24